Body Matrix Massage Therapy

Your answers to the following questions will be kept confidential. They are requested so that we may provide you with better care. Name________________________________________________________ Date ________________________ Address _____________________________________________________ Phone _________________________ City _____________________________________________________ State________ Zip________________

Age___ D.O.B.____/____/____ Sex___ Pregnant? Y / N E-Mail Address________________________________ Occupation? ________________________________ Relaxation? ________________________________________ Have you received previous massage work? Y / N How long ago was your last massage? ________________

Reason(s) for coming for massage now: __________________ Any specific areas you would like worked on? _______________________________________________________ You may use the chart on the right to indicate areas of discomfort or desired areas to work on.------------> Any major traumas you have had to your body (e.g. accident, fall, etc.). Please include ALL muscle, bone or joint injuries even if not recent, including any surgeries: ___________________________________________ ___________________________________________ Allergies (oils, lotions)?_________________________ Medications and reason?_______________________ ____________________________________________ Is there anything else we should know (health history)? ________________________________________________
I understand that the massage I receive is provided for the purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this session, I will immediately inform the therapist so that the pressure and/or strokes may be adjusted to my level of comfort. I further understand that massage should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailment that I am aware of. I understand that massage therapists are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because massage should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapists part should I fail to do so.

Client's Signature_________________________________________________ If client is under the age of 17 yrs, parent must sign form and give consent. Parent Signature ___________________________________________

Date ____/____/____

2687 North Park Drive ~ Suite 104 ~ Lafayette, CO 80026 ~ 720-934-2244 ~ www.BodyMatrixMassageTherapy.com ~ bmmt@live.com